Provider Demographics
NPI:1306823398
Name:HARDEBECK, LISA M (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:HARDEBECK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 PACIFIC AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4600
Mailing Address - Country:US
Mailing Address - Phone:253-269-6063
Mailing Address - Fax:360-539-5938
Practice Address - Street 1:621 PACIFIC AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4600
Practice Address - Country:US
Practice Address - Phone:253-269-6063
Practice Address - Fax:360-539-5938
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002596103TC2200X
WAPY2596103TC0700X
PY2596103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist